COVID-19 Parchment Affidavit
Formerly Health Screening Form
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First Name *
Last Name *
In which building will you be working? *
By Selecting YES, I confirm that I have no symptoms of COVID-19, will practice social distancing, and wear a facial covering. (If NO, please use the other box and explain why). *
By selecting YES, I confirm that I have taken my temperature and do not have a fever of 100.4 degrees or higher *
By selecting YES, I confirm that I have read the Parchment School District COVID-19 Preparedness and Response Plan. *
If you answered NO to any question above:
Call supervisor immediately to discuss your "NO" response.

*If you have a fever (100.4 degrees or higher), you must be fever free for 3 days before returning to work. If you have been experiencing respiratory symptoms, you will also need to wait to return to work until your symptoms have subsided.

Please call Primary Care Physician or Telemedicine.
If you answered YES to any question above:
No work restrictions at this time, but please call your supervisor/administrator if you begin having any symptoms or have questions on the procedures.

Your supervisor/administrator's name: *
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